NEW INDIVIDUAL
BROKERAGE ACCOUNT APPLICATION

* indicates a required entry
1. About You

First Name*
Middle Initial
Last Name*
Social Sec. No. / Tax ID* (###-##-#### or ##-#######)
Birth Date* (MM/DD/YYYY)
Home Phone* (###-###-####)
Business Phone (###-###-####)
Gender*FemaleMale

    Personal Identification Confirmation
    This information is newly required as part of our identity confirmation process.
Driver's License Number
State Issued
Date Issued
Expiration Date
or
Passport Number
Country Issued
Date Issued
Expiration Date

    Internet Access
    This information is necessary to establish internet access for your account.
E-mail Address*
Mother's Maiden Name*

    Mailing Address
    If using a PO Box as the mailing address, please provide your legal/physical address in the next address section.
Mailing Address*
City*
State* Must have a US address in Mailing OR Legal/Physical Address.
ZIP Code* (##### or #####-####)


    Legal/Physical Address
    If your legal/physical address is different from your mailing address, or if your mailing address is a PO Box, fill out this section.
Street Address
City
State Must have a US address in Mailing OR Legal/Physical Address.
ZIP Code

 (##### or #####-####)


    Citizenship
NationalityU.S.Other
Country (Required if not a U.S. Citizen)
StatusResident
Non-Resident

    Employment Information
Employment StatusEmployed
Retired
Not Employed
Occupation (Required if you are employed)
Employer (Required if you are employed)
City (Required if you are employed)
State (Required if you are employed)

    Retired or Not Employed?
    If you are retired or currently not employed, specify the amount and source of your annual income:
Amount ($#,###,###)
Source

    Financial Institution
    Information on your financial institution is required for suitability.
Financial Institution Name*
City*
State*

    Suitability - Financial Information
    Combine if filing Jointly. Exclude personal residence, automobiles, and household furnishings.
Annual Income* ($#,###,###)
Net Worth* ($#,###,###)
Liquid Net Worth* ($#,###,###)
Excluding all real estate
Investment Objective*Income
Long Term Growth
Short Term Growth
Short Term Trading
Speculation

Risk Exposure*Low
Moderate
High

Investment Experience*Minimal
Moderate
Extensive

Federal Tax Bracket*15%
28%
33%
Other
Other Amount (Required if Other)
(##)

2. Interested Party
Fill out this section if another party should receive duplicate statements and/or confirmations. For example: accountants or attorneys.

Should another party receive duplicate statements and or confirmations?

Yes
No

Name
Street Address
City
State
ZIP Code

 (##### or #####-####)


3. Account Service Instructions
For your convenience, all securities will be held in your brokerage account.

Purchase requirements and sales proceeds will be electronically transferred to/from your credit union account.

Financial Institution Name
Account Number Checking or Savings (DDA)
Account TypeChecking
Savings

ABA Routing/Transit Number This is the first nine digits on the bottom left of your check.
City
State

4. Affiliations and Acknowledgments (If Applicable)
Fill out this section if you are affiliated with, or work for a stock exchange or a member firm of an exchange or the NASD. Notification of your intent to open an account will be sent to your employer in accordance with current regulation.

I am affiliated with, or work for a stock exchange or a member firm of an exchange or the NASD

 Yes
 No
Name of Firm
Street Address
City
State
ZIP Code

 (##### or #####-####)

I am aDirector
10% Shareholder
Policymaking Executive
    Officer of a publicly
    traded company


7. Information Release

Credit Union Information Release
In order to provide me with information about financial products and services during the next twelve (12) months, I authorize BestVest Investments, Ltd. and my credit union and its affiliates to mutually share personal and financial account information. By giving the above authorization, I understand that information about me will not be disclosed to any unaffiliated third party without my permission and further, that the sharing of this information will be for the limited stated purpose of providing me information about financial products and services

8. Backup Withholding
Taxpayer Identification and Certification-Substitute Internal Revenue Service Form W-9


Under penalties of perjury, I certify (1) that the number shown on this form is my correct social security of taxpayer identification number and (2) that I am not subject to backup withholding because I am exempt from backup withholding or I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding and (3) I am a U.S. person (including a U.S. resident alien.) I must click the button in item 2b below if I have been notified by the IRS that I am currently subject to backup withholding because I have failed to report all interest and dividends on my tax return.

2b. I am subject to backup withholding.



Click the button below to proceed.